Time to re-evaluate medical standards
The recent incident in Chhattisgarh calls for a serious re-evaluation of the Government’s approach to family planning. As part of the State’s sterilization program, laparoscopic tubectomies were performed on 83 women in the Bilaspur district in a span of merely five hours. All these operations were performed by a single doctor. According to several reports, the women were operated on the floor of a dilapidated clinic. As per the governmental guidelines pertaining to sterilization operations, doctors are not supposed to perform more than 30 operations in a day with three laparoscopic instruments and not more than 50, regardless of the number of instruments.
When the women were admitted, most of them complained of vomiting and fever. However, doctors are still unsure of the cause of death. While the Government alleged medical negligence on the part of the doctor, other authorities claimed that the medicines provided were adulterated. The National Human Rights Commission and the High Court took suo moto cognizance of the tragedy and an enquiry commission was instituted to look into the matter.
The appalling incident has diverted the focus of public institutions towards the systemic flaws in the State’s approach to family planning. This incident is one in the line of many deaths that have been caused due to faulty sterilization operations. Incidents such as that in Kaparfora, Bihar, in 2012, where 53 women were sterilized in two hours in a school and Malda, West Bengal, in 2013, where unconscious women were dumped in an open field after sterilization, show scant regard for women in the approach to sterilization ((Das Abhijit, India’s latest sterilization camp massacre, The BMJ, dated 1st December, 2014, available at http://www.chsj.org/uploads/1/0/2/1/10215849/bmj.g7282.full.pdf, last accessed on 19th January,2015)).
India introduced family planning in the wake of the global propaganda surrounding the phenomena of population explosion in the 1950’s.The following decade saw the Government embark on aggressive sterilization programs that did reduce the population from around 2.3% to 1.6%. However, the national sterilization campaign was abandoned in the 1970’s itself after reports of forced sterilizations. The government’s approach towards family planning was strongly condemned for violating people’s freedom to choose and stigmatized the concept of family planning (though not as stringently as China’s one-child policy). Ever since, India has not shown any progress, with respect to population control and is fast on its way to becoming the most populous nation by 2030.
Between 2009 and 2012, the government paid pecuniary compensation to nearly 568 families of women who had lost their lives as a result of faulty sterilization operations ((Jason Burke, India mass sterilization: women were ‘forced’ into camps, say relatives, The Guardian, 12th November, 2014 available at http://www.theguardian.com/world/2014/nov/12/india-sterilisation-deaths-women-forced-camps-relatives accessed on 19th January,2015)). Such state sterilization camps are conducted on a large-scale and several health workers are roped in to convince women to undergo the surgery. These workers also receive cash benefits. Moreover, in poverty-stricken states, women are offered cash incentives and disincentives. For instance, in 2012, the Madhya Pradesh, the Chief Minister announced incentives such as DVD players for surgeons and women who accepted sterilization ((Supra, see note 1)).
In the instant case, all women who had agreed to undergo the procedure were paid Rs.1400. The payment itself is a form of coercion. This reflects the lack of regard that Governments have for the reproductive rights that women are entitled to. Most states followed a target-based approach. For instance, Chhattisgarh set a target of 180,000 women to be sterilized by the March of 2015. Such unwritten targets compel doctors and other officials to coerce women into undergoing sterilization as opposed to other, possibly safer, methods of contraception. Moreover, surgeries such as abortion are made available only if the women agree to undergo sterilization. Most women are not even informed of the available methods of contraception. Instead, priority is affixed to sterilization, which is viewed as a full-proof method substantiated by the fact that it accounts for 72% of the use of modern contraception methods.
Such incidents also highlight the poor quality of medicines within the public health system and the proliferating adulteration businesses in the pharmaceutical sector. In most hospitals, basic disinfectants are also out of supply and are watered down to cut costs. Additionally, the patient’s medical history is not examined, there is no medical equipment to perform the surgery and the post-operative environment is not conducive to recuperation ((Das A, Rai R, Singh D. Medical negligence and rights violation Economic Political Weekly 2004 Aug 28; 39(35): 3876-9)).
Another aspect of this program is its highly prejudiced approach where women are forced to shoulder the burden of the family as opposed to men. An explanation for this attitude can be in the traditional regressive notions that chastise men who undergo such operations. Tubal ligations, as a proportion of total annual sterilization operations (male or female) have increased from 71% in the early 1980s to 98% in 2013 ((Supra, see note 3.)).
From a medical perspective, sterilization is not full-proof and a woman may conceive even after undergoing the operation. Therefore, negligence charges cannot be affixed upon the doctor merely on the grounds of the operation. The Supreme Court, in its judgment in Ramakant Rai v Union of India ((Supreme Court, Civil Writ Petition No. 209/2003))and Devika Biswas v Union of India ((W.P. (C) 81 of 2012)), laid down certain guidelines in order to bring about uniformity in the surgical procedures adopted by the medical professionals. However, these directives have been incessantly violated. In response to these directives, the Government came up with the Family Planning Insurance Scheme in 2005 where it directed the Union of India and States/UTs to ensure enforcement of the union government’s guidelines for conducting sterilization procedures. This scheme covered the indemnity allowances for doctors and medical professionals up to a monetary limit of Rs 2 lakhs and as well as the damages that victims of medical negligence in sterilization operations are entitled to. This initiative created the much required safeguard for doctors, in order to encourage them to perform these operations without fear of litigation.
The fundamental right to health ingrained in Articles 14, 15, 21 and 47 of the Indian Constitution protects all citizens from such deplorable practices in the medical field. Additionally, woman have the right to voluntary sterilization services that are not coercive, unsafe or violent under the Convention on the Elimination of All Forms of Discrimination against Women (1980), the International Conference on Population and Development Cairo (1994) and the Fourth World Conference on Women, Beijing (1995) ((Shri Ramakant Rai & Health Watch UP and Bihar v Union of India and Others (SC 2003), Supreme Court, Civil Writ Petition No. 209/2003)).
It is imperative for an independent grievance redressal body to be instituted in order to assess adherence to the judicial directives and ensure that people can lodge complaints against coercive measures used against them. The State should also undertake to conduct camps to inform people about the various options available for contraception as well as the socio-economic need for family planning for the State to be support the growing population. This is the only means to facilitate accountability and culpability.